Quadriplegic Cerebral Palsy Research Articles

Outcomes of Posterior Spinal Fusion and Instrumentation in Patients With Continuous Intrathecal Baclofen Infusion Pumps

In this retrospective study, 20 spastic quadriplegic cerebral palsy (CP) patients with baclofen pumps, who underwent spinal fusion and instrumentation for neuromuscular scoliosis, were matched for weight, age, and type of fusion with patients without pumps. The objective of this study is to determine the rate of complications, adverse outcomes, and curve correction after spinal fusion in patients with CP and baclofen pumps compared with similar patients without pumps. CP patients treated with continuous intrathecal baclofen (ITB) can develop neuromuscular scoliosis and may require spinal fusion with instrumentation. ITB pumps may increase complications with this procedure. Medical records were examined, and preoperative risks, intraoperative complications, postoperative complications, and pump-specific complications were documented. Cobb angles were measured throughout the treatment to determine surgical correction. Pump patients more frequently required reoperation (9 vs. 4, P = 0.039) and rehospitalization (8 vs. 2, P = 0.008). There was a trend toward more wound infections in pump patients (5 vs. 0, P = 0.063). Nine pump patients (45%) had a pump-related complication; 5 of these patients required pump removal or revision. Complications included durotomy, tubing problems, and deep spinal infection. Average surgical correction in pump patients was 42% (81 degrees -48 degrees ) versus 50% (81 degrees -39 degrees ) in nonpump patients, with no significant difference between pairs (P = 0.11). CP patients with baclofen pumps who underwent spinal fusion had more complications compared with similar patients without pumps. There was no significant difference in surgical correction between matched pairs. Physicians and families should be aware of the increased risks of reoperation and rehospitalization after spinal fusion in the presence of baclofen pumps.

Diagnostic Evaluation Using Whole-Body Technetium Bone Scan in Children With Cerebral Palsy and Pain

Pain in noncommunicative children can be difficult to localize and diagnose. The purpose of this study is to report our experience using a 3-phase whole-body technetium bone scan as a screening tool in identifying the source of persistent pain in children with profound disabilities who cannot communicate. We reviewed the medical and imaging records of 45 patients who met the inclusion criteria of the study, which included a diagnosis of spastic quadriplegic cerebral palsy with severe motor and cognitive impairment, persistent pain of more than 1 week in duration with no recognizable source, and a 3-phase whole-body bone scan as part of the pain workup. The study group included 26 females and 19 males with an average age at presentation of 13.5 years (range, 3-20 years). A positive bone scan was seen in 24 patients (53%). The diagnosis and the source of pain were identified in all 24 patients with a positive bone scan, with the bone scan being instrumental in establishing a diagnosis or localization in 22 patients. An orthopaedic diagnosis was not established in the 21 other patients with a negative bone scan. Based on the bone scan results, additional imaging was obtained at the anatomical location indicated. The bone scan was used to establish a diagnosis of fracture in 10 of 24 patients. Other diagnoses included 3 patients with painful internal hardware, 2 with sinusitis, 2 with infections, and 1 with an obstructed kidney. Whole-body bone scan is a viable imaging option to identify the source of persistent pain in children who are noncommunicative. The bone scan can assist in localizing the source of pain and direct the location for further imaging as needed.

Prolonged, Severe Intrathecal Baclofen Withdrawal Syndrome: A Case Report

Hansen CR, Gooch JL, Such-Neibar T. Prolonged, severe intrathecal baclofen withdrawal syndrome: a case report. Intrathecal baclofen (ITB) withdrawal is a well-recognized complication when drug delivery is disrupted for any reason. ITB withdrawal varies widely in its severity and poses the very real possibility of death if not promptly managed. Cases of withdrawal lasting greater than 1 or 2 weeks, however, are sparse. We report the case of an 11-year-old girl with spastic quadriplegic cerebral palsy who developed an infected pump and subsequent meningitis, prompting the removal of her pump and catheter. She subsequently developed a severe, prolonged baclofen withdrawal syndrome marked by increased spasticity, agitation, hypertension, and tachycardia that lasted nearly 2 months, requiring intensive care and continuous intravenous sedation with benzodiazepines and opiates. Her pump was eventually replaced on hospital day 56 and within 24 hours her symptoms dramatically improved. She was eventually weaned off sedating medications and returned to baseline functional status. Typical management of baclofen withdrawal is reviewed. To date, the literature has not discussed the potential role for opiates in managing baclofen withdrawal, yet a growing body of literature is examining the interplay between opiates and γ-aminobutyric acid B pathways. A potential role for opiates in managing severe baclofen withdrawal is proposed.

Differences in pedal forces during recumbent cycling in adolescents with and without cerebral palsy

Background We showed that subjects with cerebral palsy had greater transverse and frontal plane hip and knee motion, increased duration of muscle activity, increased cocontraction, and decreased efficiency during recumbent cycling than subjects with typical development. However, it is also important to understand the forces exerted on the pedals. The purpose of this report was to compare pedal forces during cycling between adolescents with and without cerebral palsy. Methods Ten subjects (3 male, 7 female) with spastic diplegic or quadriplegic cerebral palsy (15.6 years, SD 1.8) and 10 subjects (3 male, 7 female) with typical development (14.9 years, SD 1.4) cycled on a stationary recumbent cycle at 30 and 60 revolutions per minute if able. Three-dimensional piezoelectric force transducers measured pedal forces. Data were analyzed using two-way ANOVAs. Findings Subjects with cerebral palsy spent a smaller percentage ( P < .001, r 2 = .09, power = 1.0) of the revolution applying positive force (pushing into the pedal during the extension phase) and a greater percentage ( P < .001, r 2 = .09, power = 1.0) of the revolution applying negative force (pulling away from the pedal during the flexion phase). There was no effect of cadence and no interaction effect. Interpretation These findings compliment our earlier findings of altered joint kinematics and muscle activity indicating that subjects with cerebral palsy and typical development have different cycling strategies. Methods to increase the duration of the positive force may allow subjects with CP to cycle more successfully and cycle vigorously enough to reach a heart rate necessary for improving fitness.

Different priorities: a comparison of parents’ and health professionals’ perceptions of quality of life in quadriplegic cerebral palsy

Objective:Almost all children with quadriplegic cerebral palsy (CP) have feeding difficulties. Our aim was to identify the major determinants of feeding-related quality of life (QoL) in children with quadriplegic CP...

Complicações respiratórias em pacientes com paralisia cerebral submetidos à anestesia geral

JUSTIFICATIVA E OBJETIVOS: Anestesia em pacientes com paralisia cerebral (PC) pode representar um desafio para o anestesiologista. Este estudo prospectivo teve como objetivo determinar a prevalência e o risco de complicações respiratórias em crianças com PC submetidas à anestesia geral inalatória (AGI) para tomografia computadorizada (TC). MÉTODO: Participaram do estudo pacientes com idades entre 1 e 17 anos, estado físico ASA I a III, submetidos a AGI com sevoflurano e máscara laríngea para TC no período de junho/2002 a junho/2003, divididos em três grupos: PC tetraplégicos (PCT), outros tipos de PC (PCO) e paciente sem PC (NPC). Os pais ou responsáveis responderam a um questionário com perguntas sobre o histórico médico dos pacientes, infecção de vias aéreas superiores (IVAS), asma, convulsão, incoordenação orofaríngea, refluxo gastroesofágico, etc. Dados sobre incidência e gravidade das complicações respiratórias foram coletados prospectivamente (tosse, broncoespasmo, laringoespasmo, hipoxemia, aspiração). A amostra foi calculada para uma incidência esperada de 5% no grupo NPC, com uma diferença de 15% entre os grupos (alfa = 0,05 e beta = 0,1), utilizando-se os testes do Qui-quadrado, exato de Fisher e t de Student. RESULTADOS: Compuseram a amostra 290 pacientes divididos nos grupos da seguinte forma: PCT - 100, PCO - 79 e NPC - 111. Não houve diferença na prevalência de complicações respiratórias entre os grupos PCT (4%), PCO (8,9%) e NPC (7,3%). Houve associação entre a presença de IVAS e a ocorrência de complicações (risco relativo, 10,71). CONCLUSÕES: Crianças com paralisia cerebral tipo tetraplegia espástica não parecem ter um risco aumentado de complicações respiratórias durante anestesia geral inalatória com sevoflurano e máscara laríngea. O estudo confirma IVAS como fator de risco para a ocorrência dessas complicações.

Poster 231: Botulinum Toxin Type A for Tongue Protrusion and Extrusion Disorder: A Case Report

Setting: Pediatric long-term care facility. Patient: A 17-year-old woman with spastic quadriplegic cerebral palsy (CP). Case Description: Patient had severe oral ulceration at the tongue base with secondary dysplastic overgrowth consistent with Riga-Fede disease. The lesion was secondary to frequent tongue protrusion and extrusion. Treatment required both dental and otolaryngology surgical interventions and prolonged course of medication. Botulinum toxin injection was performed to decrease aberrant tongue movements.

Growth and Nutritional Status in Residential Center Versus Home-Living Children and Adolescents with Quadriplegic Cerebral Palsy

To describe growth and nutrition in nonambulatory youth (<19 years of age) with cerebral palsy (CP) living in residential centers compared with similar youth living at home. A multicenter, cross-sectional, single observational assessment of 75 subjects living in a residential care facility compared with 205 subjects living at home. Primary outcome measures included anthropometric measures of height, weight, triceps, and subscapular skinfolds, and mid-upper-arm muscle area. Z scores were calculated from reference values for healthy children. Age, use of a feeding tube, and Gross Motor Functional Classification System (GMFCS) level were included as important confounders. Use of a feeding tube was associated with higher skinfold Z scores, and a significantly higher percentage of the residential subjects had a feeding tube. Height, weight, and arm-muscle area Z scores all diverged (negatively) from reference values with age, and the residential subjects were on average older than the home-living subjects. After controlling for age, GMFCS level and use of a feeding tube, residential living was associated with significantly greater weight, height, skinfold thicknesses, and mid-arm muscle area Z scores. Poor growth and nutrition in children with CP is a prevalent, important, and complex problem. Although factors intrinsic to the condition of CP likely play a significant role, it is also clear that environmental factors, including the living situation of the child, can have an impact.

Selective dorsal rhizotomy for spastic cerebral palsy: a review

The purpose of this report is to review the historical development, current operative techniques, selection criteria, outcomes, and complications of selective dorsal rhizotomy (SDR) for treatment of spastic cerebral palsy (CP). This review is based on a review of literature and personal observations. SDR has evolved from the 1960s onwards into a standard neurosurgical procedure for spastic CP. There is much variation in the operative technique among surgeons with respect to the level of exposure, electrophysiological guidance, and extent of rhizotomies. Appropriate selection of patients for SDR requires determination that spasticity, not dystonia, is the major disabling hypertonia and that the lower limbs are maximally involved. Positive outcomes have been well demonstrated in the impairment, functional limitations, and disability dimensions, as per the National Center for Medical Rehabilitation Research Model of Dimensions of the Disabling Process. Complications have been relatively few. SDR is the procedure of choice for treatment of spasticity in spastic diplegic CP and in selected children with spastic quadriplegic CP. Optimal selection and outcomes are achieved using a multidisciplinary approach.

Body mass index in ambulatory cerebral palsy patients

Malnutrition is a common problem in children with cerebral palsy. Although malnutrition is often recognized in patients with severe cerebral palsy, it can be unrecognized in less severely affected patients. The consequences of malnutrition are serious, and include decreased muscle strength, poor immune status, and depressed cerebral functioning. Low body mass index has been used as a marker for malnutrition. The purpose of this study was to determine which patients in an ambulatory cerebral palsy patient population were at risk for low body mass index. A retrospective chart review was performed on 75 patients. Age, sex, height, weight, type of cerebral palsy, and functional status [gross motor functional classification system (GMFCS) level] was recorded from the chart. Descriptive statistics with bivariate and multivariate regression analyses were performed. Thirty-eight boys and 37 girls with an average age of 8.11 years were included in the study. Unique to our patient population, all cerebral palsy patients were independent ambulators. Patients with quadriplegic cerebral palsy had a significantly lower body mass index than those with diplegic and hemiplegic cerebral palsy. Patients with a GMFCS III had significantly lower body mass index than those with GMFCS I and II. When multivariate regression analysis to control for age and sex was performed, low body mass index remained associated with quadriplegic cerebral palsy and GMFCS III. Malnutrition is a common health problem in patients with cerebral palsy, leading to significant morbidity in multiple organ systems. We found that in an ambulatory cerebral palsy population, patients with lower functional status or quadriplegia had significantly lower body mass index, suggesting that even highly functioning ambulatory cerebral palsy patients are at risk for malnutrition.

Evaluation of Computer-Access Solutions for Students With Quadriplegic Athetoid Cerebral Palsy

People with multiple physical impairments are not capable of using proper pointer devices, thus diminishing their opportunities to communicate and learn through computers. This research design used a replicated single-case experimental approach to compare the individual performance of two students with speech impairments and quadriplegic athetoid cerebral palsy in using four different computer-access solutions (the CameraMouse, the ASL Head Array mouse emulator, the CrossScanner, and the Quick Glance Eye Tracking System). The results demonstrate statistical significance in the correlation of movement time and accuracy to the level of comfort and satisfaction, which was used to guide the selection of computer-access solutions for clinical interventions. The WinFitts and Assessment of Comfort tests used in this study can be replicated for further clinical research into computer-access systems.

Epiphyseal separations in spastic cerebral palsy

Metaphyseal and diaphyseal fractures have been reported in children with severe spastic cerebral palsy, but there is no reference to epiphyseal separations in these patients. We report nine epiphyseal separations involving the distal femur and proximal humerus in four severely affected children with spastic quadriplegic cerebral palsy. The clinico-radiological features confirmed the cause to be scurvy. These epiphyseal separations have a good prognosis unlike the physeal injuries reported in children with myelodysplasia. Treatment with vitamin C and splintage resulted in rapid healing with excellent remodeling. Scurvy should be considered a potential cause for an epiphyseal slip in a child with severe spastic cerebral palsy. Routine dietary supplementation of vitamin C is recommended for these malnourished and nonambulant children.

Advanced Skeletal Maturity in Ambulatory Cerebral Palsy Patients

Both advanced and delayed bone age relative to chronological age have been described in non ambulatory children with moderate to severe cerebral palsy (CP). The purpose of our study was to assess skeletal maturation in an ambulatory CP population and determine the affects of body mass index (BMI), type of CP, and Gross Motor Function Classification System (GMFCS) on skeletal maturity. A retrospective chart and radiograph review was performed on 51 patients with ambulatory CP. A control group of 50 patients was also analyzed. Age, sex, height, weight, type of CP, and GMFCS were recorded from the chart. The height and weight were used to calculate BMI. Bone age was determined using the Oxford method. Statistical analysis for the data included descriptive statistics with bivariate and multivariate regression analyses. Significance was determined as P < 0.05. There were 26 boys and 25 girls. All CP patients were independent ambulators. The mean chronological age was 7.1 years for boys and 8.6 years for girls. The mean bone age was 9.9 years for boys and 10.6 years for girls. Overall, 48 (94%) of 51 patients had advanced bone age compared with chronological age. Bone age was significantly advanced compared with chronological age for boys (P = 0.033) and showed a trend toward significance in girls (P = 0.079). Bone age was advanced compared with our control population in both sexes. In multivariate analysis, quadriplegic CP type showed a trend toward significance (P = 0.066), and GMFCS III was significantly associated with advanced bone age in boys (P = 0.011). In girls, quadriplegic CP type and BMI of less than 15 were significantly associated with advanced bone age (P < 0.05 in both). Our results demonstrated that most of the ambulatory CP patients had advanced bone age compared with chronological age. Quadriplegic CP type in boys and girls contributed to advanced bone age. GMFCS III and a low BMI also contributed to advanced bone age in boys and girls, respectively. Understanding factors that lead to either delayed or advanced skeletal maturation is important in planning the appropriate timing for orthopaedic surgical intervention.

The Development and Validity of the Salford Gait Tool: An Observation-Based Clinical Gait Assessment Tool

Toro B, Nester CJ, Farren PC. The development and validity of the Salford Gait Tool: an observation-based clinical gait assessment tool. Objectives To develop the construct, content, and criterion validity of the Salford Gait Tool (SF-GT) and to evaluate agreement between gait observations using the SF-GT and kinematic gait data. Design Tool development and comparative evaluation. Setting University in the United Kingdom. Participants For designing construct and content validity, convenience samples of 10 children with hemiplegic, diplegic, and quadriplegic cerebral palsy (CP) and 152 physical therapy students and 4 physical therapists were recruited. For developing criterion validity, kinematic gait data of 13 gait clusters containing 56 children with hemiplegic, diplegic, and quadriplegic CP and 11 neurologically intact children was used. For clinical evaluation, a convenience sample of 23 pediatric physical therapists participated. Interventions We developed a sagittal plane observational gait assessment tool through a series of design, test, and redesign iterations. The tool’s grading system was calibrated using kinematic gait data of 13 gait clusters and was evaluated by comparing the agreement of gait observations using the SF-GT with kinematic gait data. Main Outcome Measures Criterion standard kinematic gait data. Results There was 58% mean agreement based on grading categories and 80% mean agreement based on degree estimations evaluated with the least significant difference method. Conclusions The new SF-GT has good concurrent criterion validity.

Inter- and Intraobserver Repeatability of the Salford Gait Tool: An Observation-Based Clinical Gait Assessment Tool

Toro B, Nester CJ, Farren PC. Inter- and intraobserver repeatability of the Salford Gait Tool: an observational-based clinical gait assessment tool. Objective To evaluate the inter- and intraobserver repeatability of the Salford Gait Tool (SF-GT), a new observation-based gait assessment tool for evaluating sagittal plane cerebral palsy (CP) gait. Design Masked comparative evaluation. Setting University in the United Kingdom. Participants A convenience sample of 23 pediatric physical therapists with varying degrees of clinical experience recruited from the Greater Manchester area. Intervention Participants viewed videotapes of the sagittal plane gait of 13 children and used the SF-GT to analyze their 13 different gait styles on 2 occasions. Eleven children had hemiplegic, diplegic, or quadriplegic CP and 2 were neurologically intact. Main Outcome Measures Inter- and intraobserver repeatability of hip, knee, and ankle joint positions at 6 different phases of the gait cycle. Results The SF-GT demonstrated good interobserver (77%) and intraobserver (75%) repeatability. Conclusions We have established that the SF-GT is a repeatable clinical assessment tool with which to guide the diagnosis, treatment planning, and evaluation of interventions by pediatric physical therapists of sagittal plane gait deviations in CP.

Agreement of aspiration tests using barium videofluoroscopy, salivagram, and milk scan in children with cerebral palsy

To study the agreement between three tests for aspiration, barium videofluoroscopy, salivagram, and milk scan we studied 63 children with severe non-ambulant spastic quadriplegic cerebral palsy (CP) aged 14 months to 16 years (32 males, 31 females). The salivagram was most frequently positive (56%, 95% confidence interval 43 to 68%); the next most frequently positive was barium videofluoroscopy when aspiration was defined as the presence of either laryngeal penetration of material or frank aspiration (39%, 95% confidence interval 26 to 53%). The milk scan was rarely positive (6%, 95% confidence interval 2 to 16%). Agreement between the tests of aspiration was poor. The maximum agreement (kappa=0.20) was between aspiration as diagnosed with the salivagram and by barium videofluoroscopy. Positive tests for aspiration are frequent in children with severe CP. Frequency varies widely depending on the investigation used. There is poor agreement between tests used for the diagnosis of aspiration. This information is of importance in assessing the significance of test results.

Transcatheter recanalization of ligated main pulmonary artery

A 12.5-year-old boy with tricuspid atresia and quadriplegic cerebral palsy presented with increasing cyanosis after previous palliation with a cavopulmonary shunt and ligation of the main pulmonary artery (MPA). Because of severe physical disabilities he was not considered suitable for Fontan completion. He underwent successful transcatheter stent recanalization of the ligated MPA. This re-established anterograde flow to the pulmonary arteries resulting in marked improvement in saturations.

Definition and classification of GP: medical-legal and service implications

The implications of a revised definition and classification system for cerebral palsy (CP) obviously extend well beyond clinical care and research. My commentary will focus on two disparate areas of concern: specific topics related to medicallegal issues and brief comments concerning potential effects on service provision. Important issues from the medical-legal perspective include the definition itself and issues relevant to causation in the classification section, specifically neuroimaging and etiological understanding. For nearly 150 years, causation theories for CP have been linked to intraparturn events. Despite decades of epidemiological research to the contrary, the causal connection in the public mind between CP: ‘brain damage’, and obstetrical misadventure continues to encourage litigation with highly significant professional and economic implications for health care and society.24 Consensus publications identify spastic quadriplegic and/or dyskinetic CP as an essential criterion for consideration of intraparturn hypoxic-ischemic injury as the cause of later disab i l i t~ .~ .~ The revised definition does not affect this perspective. Despite initial concerns that the new term ‘disturbances’ might broaden the concept of CP to include children with developmental coordination or dyspraxic conditions, the full document clearly specifies patterns of motor disability as spastic, dyskinetic, or ataxic and thereby preserves the traditional designations and relationship between CP pattern and potential etiologies. In the Classification section, the brief comments on neuroimaging are noteworthy. The committee correctly notes that the classification of CP by imaging criteria is still in development but forcefully endorses the previous recommendation of the American Academy of Neurology on the importance of such testing whenever feasible.’ This statement cannot be over-emphasized in the medical-legal context. Currently, allegations of ‘brain injury’ do not require the demonstration of such injury or in fact, any anatomic abnormality. This unfortunately permits CP and other impairments to be presented as evidence of ‘brain injury’ a seriously uninformed perspective. Such a view fails to acknowledge the value of MRI in identifying injury patterns, and even more importantly, overlooks the significance of brain malformations and genetic/ metabolic disorders in producing the CP phenotype. The critical issues of causation and timing are also addressed directly in the revision document. The annotation on the definition states that ‘a full understanding of causal pathways and mechanisms leading to CP remains elusive’ and then amplifies this perspective in the section on Cause and Timing. In discussing causation, the current understanding of the importance of multiple interacting risk factors, the lack of a specific etiological relationship between adverse circumstances and CE and the absence of a known cause in many cases are stated explicitly. This section concludes with the important caveat that, ‘clinicians should avoid making the assumption that adverse events in the prenatal, perinatal, and postnatal life of a child with CP [are] sufficient to permit an etiological classification that implies a causal role for these events in the genesis of CP’. In summary, the committee’s statements provide an authoritative reminder about what is actually known and not known about causation and will be useful to those who are asked to render legal opinions in cases involving CP. With respect to service provision, the diagnosis of CP is generally understood to indicate the presence of significant motor impairments which require educational and community-based services. The new definition maintains the central position of motor impairment but expands the focus considerably by emphasizing the importance of associated neurodevelopmental and musculoskeletal complications. The revision also places these impairments in a functional context by adopting the World Health Organization concept of ‘activity limitation’ as a defining criterion.8 These are significant modifications of the traditional focus on motor impairments alone and should have a major impact on services for those with CI! Care providers, educational institutions, advocacy groups, policy makers and others will need to adapt current approaches by placing increased emphasis on associated impairments as they consider the multiplicity of challenges facing individuals with CP. Such an expansion of the core concept of CP is likely to challenge current systems of care. Carried to their logical extent these changes in definition present rather daunting challenges and are likely to require significant modifications in the application of economic and manpower resources. Despite these practical difficulties, the revised definition presents a welcome opportunity to broaden the focus on CP. I believe that the net effect will be to stimulate progress on multiple fronts including neurobiological understanding, management approaches, and societal participation.

Functional Outcomes of Intramuscular Botulinum Toxin Type A and Occupational Therapy in the Upper Limbs of Children With Cerebral Palsy: A Randomized Controlled Trial

Wallen M, O’Flaherty SJ, Waugh MC. Functional outcomes of intramuscular botulinum toxin type A and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial. Objective To investigate the functional outcomes of botulinum toxin type A (BTX-A) injections to the upper limb in combination with occupational therapy (OT) in children with cerebral palsy (CP). Design Randomized controlled trial with follow-up at 2 weeks, 3 months, and 6 months. Setting Specialist outpatient physical disabilities clinic within a public pediatric teaching hospital. Participants Eighty children with spastic quadriplegic, triplegic, or hemiplegic CP from these clinics were randomly assigned to BTX-A plus OT, BTX-A alone, OT alone, or a no-treatment control group. Interventions Single set of BTX-A (Botox) injections and 12 weeks of OT. Main Outcome Measures Canadian Occupational Performance Measure (COPM) and Goal Attainment Scale (GAS). Results The combination of BTX-A and OT resulted in accelerated attainment of functional goals measured by the COPM and GAS. There were no differences between groups on the Melbourne Assessment of Unilateral Upper Limb Function, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, Child Health Questionnaire, or active and passive range of motion. As expected, there was a significant reduction in muscle tone at follow-up 2 weeks after injection, which returned to baseline level by 6 months. Conclusions OT enhanced individualized functional outcomes following BTX-A injections in the upper limbs of children with CP.

Health professionals’ perceptions of feeding‐related quality of life in children with quadriplegic cerebral palsy

Our aim was to identify the major determinants of feeding-related quality of life (QoL) in children with quadriplegic cerebral palsy (QCP) from the perspective of health professionals to provide a framework for comprehensive clinical evaluation of health status in this group. A trained facilitator conducted five semi-structured focus groups during September and November 2003. Participants were recruited through the two paediatric hospitals in Sydney and community-based services, and included general and specialist paediatricians (n = 18), nurses (n = 15) and allied health professionals (n = 13), with an 80% response rate. All sessions were audio- and videotaped. NVIVO software was used to facilitate thematic analysis of the transcribed audiotapes. Responses clustered into five themes: delivery of health services, parent-child interaction, the child's physical and emotional well-being, and social participation. Participants thought the QoL of child and parent was inseparable. Parent-child interaction, delivery of services and physical well-being were the topics which prompted most participant interaction. These findings did not vary across disciplines. Health professionals identified five domains which provide a framework within which clinicians may comprehensively evaluate the health status of children with QCP and feeding difficulties. These five domains may also be used to inform a new feeding-related QoL instrument for use in this group of patients.